Male partners’ participation in birth preparedness and complication readiness in low- and middle-income countries: a systematic review and meta-analysis

Background: Maternal and neonatal health outcomes remain a challenge in low- and middle-income countries (LMICs) despite priority given to involving male partners in birth preparedness and complication readiness (BPCR). Men in LMICs often determine women’s access to and affordability of health services. This systematic review and meta-analysis determined the pooled magnitude of male partner’s participation in birth preparedness and complication readiness in LMICs. Methods: Literature published in English language from 2004 to 2019 was retrieved from Google Scholar, PubMed, CINAHL, Scopus, and EMBASE databases. The Joanna Briggs Institute’s critical appraisal tool for prevalence and incidence studies were used. A pooled statistical meta-analysis was conducted using STATA Version 14.0. The heterogeneity and publication bias were assessed using the I2 statistics and Egger’s test. Duval and Tweedie’s nonparametric trim and fill analysis using the random-effect analysis was carried out to validate publication bias and heterogeneity. The random effect model was used to estimate the summary prevalence and the corresponding 95% confidence interval (CI) of birth preparedness and complication readiness. The review protocol has been registered in PROSPERO number CRD42019140752. The PRISMA flow chart was used to show the number of articles identified, included, and excluded with justifications described. Results: Thirty-seven studies with a total of 17, 148 participants were included. The pooled results showed that 42.4% of male partners participated in BPCR. Among the study participants, 54% reported having saved money for delivery, whereas 44% identified skilled birth attendants. 45.8% of male partners arranged transportation and 57.2% of study participants identified health facility as a place of birth. Only 16.1% of the male partners identified potential blood donors. Conclusions: A low proportion of male partners were identified to have participated in BPCR in LMICs. This calls countries in low- and middle-income setting for action to review their health care policies, to remove the barriers and promote facilitators to male partner’s involvement in BPCR. Health systems in LMICs must design and innovate scalable strategies to improve male partner’s arrangements for a potential blood donor and transportation for complications that could arise during delivery or postpartum haemorrhage. The search strategy aimed to locate both published and unpublished literature. A preliminary search was done on Google Scholar database to identify the availability of articles on the topic. Key terms were adapted as appropriate for each database and site, with combination of MeSH terms and text words using Boolean operators “AND” and “OR” running key search topics for electronic databases such as PubMed, EMBASE, CINAHL, and Scopus (Additional file 1). The reference lists of all studies selected for critical appraisal were screened for additional studies. Both institutional and community-based cross-sectional studies published in English language from January 2004 to December 2019 were included. Following the search, all identified citations were organized and uploaded into EndNote version 15.0 and duplicates were removed. Titles and abstracts were screened by two independent reviews and double-checked by a third reviewer for assessment against the in- and exclusion criteria. Potentially relevant studies were retrieved in full including their citation details. Literature was eligible for inclusion if they reported the involvement of male partners of pregnant women and nursing mothers in BPCR in LMICs as participants in the study. Studies which reported the magnitude of male partners’ participation in BPCR as the main outcome were included. Systematic reviews, studies conducted on women participation in BPCR, studies with poor methodological quality after a quality assessment and reports of studies conducted in high-income countries were excluded. The full text of selected citations was assessed in detail against the inclusion criteria by two reviewers and double-checked by two other independent reviewers. Reasons for exclusion of studies that did not meet the inclusion criteria up on full text screening were recorded and reported. Any disagreements that arose between the reviewers at each stage of the study selection process were resolved through discussion, or with a third reviewer. The results of the search were reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram (Fig. ​(Fig.1)1) [55]. Flow diagram of the included studies. Moher, D., et al., Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Medicine, 2009. 6(7) Defined as planning and organizing during pregnancy in preparation for a normal delivery or in case of complications [50, 56, 57]. The BPCR practices involves saving money for delivery; identifying transport and the location of birth of the baby; knowing danger signs of pregnancy complications [58]; identifying a skilled birth attendant and a potential blood donor [50, 56, 57]. Complications were defined as: Immediate, life threatening pregnancy or labour complications [57]. Is defined as a strategy of promoting the active use and retaining of well-trained human resource for maternal and neonatal health, especially during childbirth and postpartum care, based on the theory that arranging for childbirth and being prepared for complications decreases delays in receiving this care [11, 59–62]. Refers to the knowledge, attitude, and behavioral practices associated to BPCR and emergency obstetric care by male partners of pregnant women and nursing mothers within the 42 days of the delivery of the neonate [19, 56, 63–69]. The data were extracted from included studies using the data extraction tool prepared by MTB. The tool includes variables such as the name of the author, publication year, study design, data collection period, sample size, study area, and the prevalence of birth preparedness and complication readiness. The data extraction tool contains information on the percentage of male partners who saved money for the birth of the baby, prepared a potential blood donor, identified a skilled birth attendant, and knows danger signs, arranged transportation, and identified a health facility as place of delivery of the baby. MTB extracted the data, and HT and MY cross-checked the extracted data for its validity and cleanness. Authors of papers were contacted to request missing or additional data. Eligible studies were critically appraised by two independent reviewers (MTB and MY). Methodological quality was assessed using the JBI’s standardized critical appraisal instrument for incidence and prevalence studies. The results of the critical appraisal were reported in narrative form and a table. A lower risk of bias (90%) observed after assessment (Table ​(Table11). Descriptive summary of 37 studies included in the meta-analysis of the pooled magnitude of male partners’ participation in birth preparedness and complication readiness in low- and middle-income countries, 2004 – 2020 Studies with inadequate sample size, inappropriate sampling frame and poor data analysis were excluded. Articles were reviewed using titles, abstracts, and full text screening. Full texts of included studies were examined using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) for critical appraisal tool (Table ​(Table11). Included studies were pooled in a statistical meta-analysis using STATA version 14.0. Effect sizes were expressed as a proportion with 95% confidence intervals around the summary estimate. Heterogeneity was assessed using the standard chi-square I2 test. A random-effects model using the double arcsine transformation approach was used. Sub-group analyses were conducted to investigate the level of male partner participation in the SSA and Asian regions. Sensitivity analyses were conducted to test decisions made regarding the included studies. Visual examination of funnel plot asymmetry (Fig. ​(Fig.2)2) and Egger’s regression tests were used to check for publication bias [70]. A Forest plot with 95% CI was computed to estimate the pooled magnitude of male partners’ participation in birth preparedness and complication readiness in LMICs. Funnel plot used to assess possible publication bias of studies published from 2004 to 2020 The review protocol has been registered in PROSPERO with protocol registration number CRD42019140752 [71].